Health inspection·September 12, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 7 (Resident #1) residents reviewed for medical records. The facility failed to accurately document elopement information in Resident #1's records. This could place all residents at risk for elopement for inaccurate assessments in medical records. Findings include: Record review of Resident #1's face sheet, dated 9/12/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included but are not limited to Unspecified Anemia, Unspecified dementia, moderate, with other behavioral disturbances, and Major Depressive Disorder. Record review of Resident #1's MDS, dated [DATE], Section C for Cognition, resident had a BIMS of 11 of 15 indicating mild cognitive impairment. Record review of Resident #1's care plan, dated 8/26//26, indicated a risk of elopement. Record review of Resident #1's elopement risk assessment, dated 5/14/23, indicated on question 3 a YES answer to the resident having a history of elopement or an attempted elopement while at home. Record review of Resident #1's elopement risk assessment, dated 8/14/23, indicated on question 3 a YES answer to the resident having a history of elopement or an attempted elopement while at home. Record review of Resident #1's elopement risk assessment, dated 8/20/23, indicated on question 3 a NO answer to the resident having a history of elopement or an attempted elopement while at home. Record review of Resident #1's progress notes, dated 8/19/23, indicated that resident was hitting windows to Periwinkle (locked) unit indicating that he wanted to go home. Resident was placed with one on one supervision. Record review of Resident #1's progress notes, dated 8/20/23, indicated a staff member who was not working found the resident walking down the street and returned him to the facility. Interview with ADM on 9/12/23 at 12:40 PM, indicated that ADON or DON are responsible for elopement (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 675117 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)